Management of Small Bowel Obstruction with Microperforation
No, do not place an NG tube on low suction in a patient with small bowel obstruction and microperforation—this patient requires immediate surgical intervention, not conservative management. 1, 2
Why Surgery is Mandatory
Microperforation is an absolute contraindication to conservative management. The presence of perforation, even microscopic, indicates bowel wall compromise that will not resolve with decompression alone and carries high risk of progression to frank perforation, peritonitis, and sepsis. 1, 3
Signs of peritonitis, strangulation, or bowel ischemia mandate immediate surgical exploration without attempting non-operative management. Microperforation falls into this category as it represents established bowel wall failure. 1, 2
Mortality reaches 25% when ischemia or perforation is present, and delays in surgical intervention significantly increase morbidity and mortality. 2, 4
The Role of NG Tubes (When Appropriate)
For context, NG tube placement on low intermittent suction (40-60 mmHg) is the cornerstone of conservative management for uncomplicated SBO only—meaning no signs of perforation, peritonitis, strangulation, or ischemia. 1, 2
When NG tubes ARE indicated:
- Simple adhesive SBO without complications where conservative management is appropriate 1, 4
- Prevention of aspiration pneumonia in patients with significant vomiting and gastric distension 2, 3
- Symptomatic relief by removing accumulated fluid and gas proximal to the obstruction 2
Technical details for uncomplicated cases:
- Low intermittent suction (40-60 mmHg) prevents mucosal injury compared to high continuous suction, which can cause the tube to adhere to and damage gastric mucosa 2
- Radiographic confirmation of tube position is mandatory before use, as bedside auscultation is unreliable and can miss malposition in the lung or esophagus 2, 5
Critical Red Flags Requiring Surgery
Your patient has already met surgical criteria with microperforation, but for completeness, other absolute indications include:
- Peritonitis on examination 1, 2
- Fever, hypotension, diffuse abdominal pain suggesting strangulation 2, 3
- Elevated lactate indicating bowel ischemia 2
- CT findings of closed loop obstruction, bowel ischemia, or free fluid 1
- Failure of conservative management after 48-72 hours (not applicable here—you shouldn't even start conservative management) 1, 5
Immediate Management Steps
- NPO status and aggressive IV fluid resuscitation to correct dehydration and electrolyte abnormalities 1, 2
- Broad-spectrum IV antibiotics to cover enteric organisms given the perforation 1
- Immediate surgical consultation for exploratory laparotomy 1, 3
- Serial lactate monitoring and hemodynamic support as needed 2
Common Pitfall to Avoid
Do not be misled by the "micro" prefix—any perforation, regardless of size, represents full-thickness bowel wall compromise that requires surgical repair. Conservative management with NG decompression is only appropriate for simple, uncomplicated SBO where the bowel wall integrity is intact. 1, 4